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W.A.T.A. Filter Setup & Follow-Up Survey
Please select the type of visit below: either “Initial Filter Setup” or a "Follow-Up" visit. The questions will update automatically based on your selection. Complete this survey once per household visit to track installation, usage, and impact. Make sure to answer all required questions and upload a photo if possible. Thank you so much for helping make this all possible.
SECTION 1: Family & Visit Information
1. Location
*
Vietnam
Myanmar
Guatemala
Other
2. Community/Village/Town
3. Type of Visit?
*
Initial Setup
Follow Up
4. Date of Visit
*
/
Month
/
Day
Year
Date
5. Filter Recipient Name
Who is getting the filter? Name / School / etc
6. Recipient Contact (if applicable)
Phone Number / Email / etc
7. Filter(s) Set Up By:
WATA Ambassador/Team Member
8. # of People in Household
9. How do they currently get their water?
Local Well
River/Lake/Natural Source
Community Tap/Shared Faucet
Rainwater
Purchase Bottles/Jugs
Other
10. How do they currently purify their water?
Boiling
Chemicals
Other Filter
Nothing
Other
9.1. How much does it currently cost?
Cost / Week -or- Cost / Month
11. Does the Family currently experience health issues from water?
Yes
No
11.1. What are the issues?
Diarrhea / Stomach Problems
Vomiting
Skin Rash
Fever or Recurring Sickness
Missed School / Work
Dental Issues
Other
SECTION 2.1: Initial Filter Setup
Initial Filter Setup
Record the installation of a new water filter, including materials provided, training given, and household information.
1. Was this part of a group or individual setup?
Group Lesson
Individual
Other
2. How Many Filters Are Being Set Up
3. What materials were provided?
Sawyer Filter
Bucket
Hose/Adapter/Components
Backflush Syringe
Training Materials
Solar Light
Other
4. Was a demonstration or training given?
Yes
No
4.1. What topics were covered?
How To Assemble
How to Backflush/Clean
How to Use Filter
How to Store the Filter
When To Clean
Health and Hygiene Tips (WASH)
Where to Get Help
Other
5. Comments About the Training
SECTION 2.2: Filter Follow-Up/Check-In Questions
Filter Follow-Up & Check-In
Check in on an existing filter to track usage, maintenance, impact, and any support the family may need.
1. Which filter follow-up is this?
1-Month Follow-Up
6-Month Follow-Up
1-Year Follow-Up
Other
2. When was the filter first set up?
Month / Year
3. Who collects the water?
4. When did you use the filter last?
5. Is the filter working?
Yes
Some Issues
Not Working
5.1. What problems are you experiencing with the filter?
It’s too slow
It leaks
It’s clogged
Parts are missing or broken
I don’t know how to clean or use it
Other
6. How often do you use the filter?
Daily
A few times a week
Weekly
Rarely
Not using it
6.1. Why don't you use the Filter more often?
No Time
I forget to use it
I’m used to another method
I don’t trust the filter
I didn’t understand how to use it
I lost/broke a part
It’s too slow
It’s hard to clean or maintain
No bucket or container
Didn’t notice a difference
Other
7. What do you use the Filtered Water For?
Drinking water
Cooking
Washing
Animals
Other
8. Where did you get the water before using the filter?
Local Well
River/Lake/Natural Source
Community Tap/Shared Faucet
Purchase Bottles/Jugs/Tanks
Rainwater
Other
8.1. How long did it take to collect the water from Local Well?
Less than 15 min
15-30 minutes
30-60 minutes
Over 1 hour
8.2. How long did it take to collect the water from River/Lake?
Less than 15 min
15-30 minutes
30-60 minutes
Over 1 hour
8.3. How many? How much did you pay? How Often?
8.3.1. Monthly Cost ($)
Please calculate this
8.4. Is the tap always available and clean?
Yes
Sometimes
No
9. Have you noticed any changes since using the filter?
Improved health
Saves Money
Better taste
Less Time Boiling Water
No noticeable changes
Other
9.1. What Health changes?
Fewer stomachaches
Less diarrhea
Fewer sick days
No change
Not sure
Other
10. How often do you backflush the filter?
Daily
Every couple days
Weekly
Monthly
Never
10.1. Why don't you backflush the filter?
I don't know how
Syringe is broken or Lost
I didn't know I had too
I don't have time
I forgot
Other
11. Would you recommend this filter?
Yes
No
Not Sure
12. Has anyone asked about it?
Yes
No
12.1. If yes, Who?
SECTION 3: Final Details & Uploads
Final Details & Uploads
Use this section to include any last notes, photos, or location details from your visit. These help us verify setups, track progress, and improve support for each household.
1. Location Address (If Possible)
Street Address (If Possible)
Directions to Household
City/Town/Village/Community
State / Province
Postal / Zip Code
2. Take Photo
3. Upload Photo of Filter & Family
Browse Files
Drag and drop files here
Choose a file
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of
4. NOTES/COMMMENTS
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